MAUDE MDR 5502887

MDR report key
5502887
Report number
3006217371-2016-00005
Event key
0
Event type
3
Date of event
2016-01-12
Date received
2016-03-15
Adverse event
3
Product problem
3
Patients in event
0
Reporter occupation
1
Health professional
3
Initial report to FDA
3
Event location
3

Manufacturer Contact#

Contact
MS LORRAINE CALZETTA
Address
488 WHEELERS FARMS ROAD MILFORD CT 06461 US
Phone
203-203-2037
Report source
M
Manufacturer link flag
Y

Devices#

Seq, Brand, Generic table
SeqBrandGenericManufacturerProduct codeModelCatalogLotPMA510(k)ImplantEvaluatedAvailability
1AIRSEALTROCARSURGIQUEST,INC.GCFUNKR *

Patients#

Sequence, Received, Treatment table
SequenceReceivedTreatmentOutcome
12016-03-150

Event Narratives#

N

Patient 1

A CORRECTION WAS MADE TO THE ORIGINAL INFORMATION PROVIDE BY THE USER FACILITY IN THAT THE FAN LIVER RETRACTOR WAS SECURED TO A BOOK WALTER INSTRUMENT HOLDER CLAMPED ONTO THE PATIENT'S BED, AND WAS SCREWED ONTO THE LIVER RETRACTOR AS STANDARD PRACTICE. THE USER FACILITY INDICATED THAT THE DEVICE WAS AVAILABLE FOR EVALUATION. HOWEVER THE DEVICE COULD NOT BE LOCATED . GOOD FAITH EFFORTS TO OBTAIN THE DEVICE HAVE BEEN UNSUCCESSFUL. WITHOUT THE ACTUAL PRODUCT AN EVALUATION COULD NOT BE PERFORMED. THE MODEL NUMBER PROVIDED DOES NOT EXIST , BUT IS SIMILAR TO OTHER MODEL NUMBERS MANUFACTURED BY SURGIQUEST . THE LOT NUMBER WAS NOT PROVIDED, BECAUSE THE EXACT MODEL NUMBER AND LOT NUMBER WERE NOT PROVIDED, A REVIEW OF THE DEVICE HISTORY RECORD COULD NOT BE PERFORMED. IN THE EVENT THAT THE DEVICE IS RETURNED, A FOLLOW-UP REPORT WILL BE MADE. THE COMPANY CONTINUES TO MONITOR THE CLINICAL USE OF AIRSEAL IFS AND WORKS DILIGENTLY TO ENSURE PRODUCT SAFETY.

D

Patient 1

ON (B)(6) 2016, SURGIQUEST WAS MADE AWARE OF A PURPORTED MALFUNCTION WITH ONE OF ITS DEVICES VIA DISTRIBUTOR. THE EVENT TRANSPIRED IN (B)(6). IT WAS PURPORTED THAT DURING A MINIMALLY INVASIVE TOTAL GASTRECTOMY, USING A 12MM AIRSEAL PORT, WHEN THE TROCAR WAS REMOVED A 1X1CM PIECE OF THE BOTTOM PLASTIC WAS MISSING. THE FRAGMENT WAS RETRIEVED FROM THE PATIENT . THE USER FACILITY SUBMITTED THE REPORT AS A SERIOUS INJURY HOWEVER REPORTED TO SURGIQUEST THAT THE FRAGMENT WAS LOCATED QUICKLY AND THERE WAS NO MEDICAL INTERVENTION OR ADVERSE ISSUES TO THE PATIENT. ADDITIONAL INFORMATION REPORTED REGARDING THE EVENT IS AS FOLLOWS: "THE 12MM AIRSEAL ACCESS WAS OBSERVED AND ALL APPEARED NORMAL WITH THE PRODUCT, A STANDARD COVIDIEN FAN LIVER RETRACTOR, ATTACHED TO THE ROBOTIC ARM, WAS INSERTED AND UTILIZED THROUGH THE 12MM ACCESS PORT. THE FAN LIVER RETRACTOR AND ACCESS PORT REMAINED FIXED IN PLACE THROUGHOUT THE ENTIRE PROCEDURE, BUT WHEN REMOVED IT WAS NOTICED THAT A PORTION OF THE DISTAL TIP OF THE 12MM AIRSEAL ACCESS PORT WAS MISSING". THE MODEL NUMBER WAS REPORTED AS IAS12-120AI.